Case Study #2

Case History Patient 38-year-old female. Chief Complaint Severe headache, nausea, vomiting, and palpitations. History of Present Illness The patient presented to the emergency department (ED) with headache, nausea, vomiting, palpitations, severe dyspnea, diaphoresis, and sinus tachycardia that was treated with metoprolol (beta blocker). Her electrocardiogram (ECG) showed ST-segment depression in several leads. Because of increasing concentrations of cardiac troponin I (cTnI) and creatine kinase (CK), an acute coronary syndrome was presumed. The patient was treated with aspirin, heparin, tirofiban, and intravenous metoprolol and transferred to the university center for invasive diagnostic procedures. During transport, her condition worsened with development of pulmonary edema requiring intubation and mechanical ventilation. Subsequently, however, she became hemodynamically unstable with a heart rate of 152 and BP drop to 55/38 and, on 2 occasions, required inotropic support and a short episode of cardiopulmonary resuscitation. Past Medical History History of migraine headaches since childhood and short episodes of palpitations during the last year not documented by ECG and no cardiovascular risk factors, especially no history of hypertension. Family History Noncontributory. Physical Exam Findings In the ED, she was afebrile and had a sinus rhythm with a heart rate of 100 beats/min (bpm) and blood pressure of 176/117 mm Hg. The day after admission to the center, she developed a fever (39.5°C), her C-reactive protein (CRP) level was elevated, and she was hypertensive (170/120 mm Hg) with a sinus tachycardia of up to 160 bpm. Principal Laboratory Findings Additional Diagnostic Procedures Emergency heart catheterization excluded coronary artery disease but showed a severely depressed left ventricular ejection fraction (LVEF) of 20%. A cerebral computed tomography (CT) scan showed no evidence of bleeding. A CT scan of the chest and abdomen was negative for infectious foci; however, a left adrenal mass was noted. In addition, toxicology, serologic, and microbiology tests (ie, blood cultures) were all negative. The presence of the adrenal mass prompted collection of a 24-h urine sample for quantification of catecholamines. The patient's cardiac function improved, and repeat echocardiography, performed 2 weeks after admission to the center, revealed normal heart wall motion and left ventricular function. Moreover, she was normotensive but still showed intermittent sinus tachycardia. Questions 1. What are this patient's most striking (concerning/abnormal) clinical and laboratory findings? 2. How do you explain these findings? 3. What is the differential diagnosis (what are the various possible causes of these findings)? 4. What is this patient's most likely diagnosis? 5. What is the pathogenesis of this patient's disease? 6. What is the most appropriate (priority) treatment for this patient's disease? What type of shock did this patient experience?